Provider Demographics
NPI:1194289405
Name:SOUTHERN, CHELSEY (PA-C)
Entity type:Individual
Prefix:
First Name:CHELSEY
Middle Name:
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8508 HORNBEAM DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-5048
Mailing Address - Country:US
Mailing Address - Phone:817-300-6727
Mailing Address - Fax:
Practice Address - Street 1:6401 HARRIS PKWY STE 120
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6100
Practice Address - Country:US
Practice Address - Phone:817-346-9111
Practice Address - Fax:817-346-9714
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXA13241363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant